Coroner's Finding: Kranz, Lothar Wolfgang

85y · Male·Advanced atherosclerotic coronary artery and peripheral vascular disease complicating endovascular repair of an abdominal aortic aneurysm under general anaesthesia

An 85-year-old man with ischaemic heart disease, COPD, and diabetes underwent endovascular repair of a recurrent abdominal aortic aneurysm with endoleak using a novel chimney technique with Nellix endobags. The procedure was appropriately planned and executed, but the right endobag ruptured during polymer injection. Although the endoleak was successfully sealed, the patient developed acute right leg swelling and hypotension in recovery, progressing to death despite fasciotomy. Autopsy confirmed severe atherosclerotic disease and a ruptured endobag with minimal polymer, but could not definitively prove polymer-related injury caused the acute decompensation. The coroner found proper care was exercised; the complication was unexpected and unforeseeable. The hospital subsequently ceased using this device.